NCGNE0033_COMPLETE FILE - HISTORICAL_20121105

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STORMWATER DIVISION CODING SHEET
.NCG PERMITS
PERMIT NO.
NCGNE L)
DOC TYPE
HISTORICAL FILE
DOC DATE
p-�o) � I D 5
YYYYMMDD

A74 Division of Water Quality / Surface Water Protection
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National Pollutant Discharge Elimination System
NCDENR
""""""°LINA O`�""T "�°' PERMIT NAME/OWNERSHIP CHANGE FORM
ENviaa«Hu+r .wo "avau. Rr_eq�nees
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
1. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N C S 10 1 1 1 1 N I C I Ci I N I E 1 0 0 3 3
11. Permit status prior to requested change.
a. Permit issued to (company name): Cooper Bussmann, Inc.
b. Person legally responsible for permit: Mitchell K. Medford
First M1 Last
Plant Manager
Title
210 Dixie Trail
Permit Holder Mailing Address
Goldsboro NC 27530
City State Zip
[phone] xt. 103 [phone]
Phone Fax
c. Facility name (discharge): Cooper Bussmann, Inc.
d. Facility address: 210 Dixie Trail
Address
Goldsboro NC 27530
City State Zip
e. Facility contact person: William M. Graham [phone] xt. 147
First / MI / Last Phone
IIl, Please provide the following for the requested change (revised permit).
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for permit
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
Cooper Bussmann, LLC _
Mitchell K. Medford
First M l Last
Plant Manager
Title
210 Dixie Trail
Permit Holder Mailing Address
Goldsboro NC 27530
City State Zip
M itche l 1. M ed ford@Cooper) ndustri es.c
919 734-3900 om
Phone E-mail Address
Cooper Bussmann, LLC
210 Dixie Trail
Address
Goldsboro NC 27530
City State Zip
William M. Graham
First MI Last
[phone] _Mike,[e-mail]
Phone E-mail Address
Revised 2012Apr23

r
NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: William M. Graham
First MI Last
Environmental Coordinator
Title
210 Dixie Trail
Mailing Address
Goldsboro NC 27530
Citv State 'Lip
[phone] [e-mail]
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
® This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is re uired for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
1, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
1, Mitchell K. Medford, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information is not included, this application
package will be returned as incomplete.
1UW ]Uhila
Siglature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 712008

br Trail Goldsboro,
S
Goldssbooro, NC 27530
Phone: (9 70D, Exi. 147 COOPER
Fax: [phone]
e-mail: [e-mail]
To: North Carolina Department of Environment and Natural Resources
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699-1617
From: Mike Graham
Bussmann
Subject: NPDES Certificate of Coverage NCGNE0033 — Permit Name/Ownership Change Form
Date: October 31, 2012
Enclosed please find our completed Permit Name/Ownership Change Form for our NPDES No
Exposure Certification.
If you should have any questions, please contact me at [phone], ext. 147, or via email at
Mike.Graham a Cooperindustries.com.
Regards,
Mike Graham
Environmental Coordinator

OF \NA T,E
Michael F. Easley, Governor
TQ�
William G. Koss Jr., Secretary
North Carolina Department of Hnvironment and Natural Resources
_O�
r
Alan W. Klimck, P. S. Director
Division of Water Quality
0
Coleen 11. Sullins, Deputy Director
Division of Water Quality
April 20, 2005
Doug May, Manager Site
Doug May
210 Dixie Tri
Goldsboro, NC 27530
Subject: No Exposure Certification NCGNE0033
Cooper Bussmann Inc - 210 Dixie TO
Wayne County
Dear Permittee:
The Division has reviewed your submittal of the No -Exposure Certification for Exclusion from NPDES
Stormwater Permitting form, which we received on August 12, 2003. We apologize for the extended period it
has taken us to get back to you on this request and we appreciate your patience as we have worked through
this process. Based on your submittal and signed certification of no exposure at the above referenced facility
the Division is granting your certification as provided for under 40 CFR 126.22(g) which is incorporated by
reference in North Carolina regulations.
Please note that by our acceptance of your no exposure certification, you are obligated to maintain no
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for a no -
exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your stormwater
discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted discharge. Your
conditional no -exposure exclusion expires in five years (April 30, 2010). At that time you must re -certify with
the Division, or obtain NPDES permit coverage for any Stormwater discharges from your facility.
Your certification of no exposure does not affect your facility's legal requirements to obtain environmental
permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jonathan Diggs at [phone] ext.
537, or at [e-mail].
Sincerely,
for Alan W. Klimek, P.E.
cc: Washington Regional Office - Central Files — wlattachments
Stormwater Permitting Unit Files
N. C. Division of Water Quality 1617 Mail Service Center Raleigh, North Carolina 27699-1617 [phone]
�ZA
NEDI hlR
Customer Service
1-877-623-6748

United States Environmental Protection Agency aForm Approved
g y oMe No.2oaaa211
NPDES ;' ��� Washington, DC 20460
FORM '� NO EXPOSURE CERTIFICATION for Exclusion from
3510-11
NPDES Storm Water Permitting
Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its storm water
discharges associated with industrial activity in the State identified in Section B under EPA's Storm Water Multi -Sector General Permit due to the existence
of a condition of no exposure,
A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to prevent
exposure to rain, snow, snowmelt, andlor runoff. Industrial materials or activities include, but are not limited to, material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities include the storage,
loading and unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product. A storm resistant shelter is
not required for the following industrial materials and activities:
drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed"
means banded or otherwise secured and without operational taps or valves;
— adequateiy maintained vehicles used in material handling; and
— final products, other than products that would be mobilized in storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. in addition, the exclusion from NPDES permitting is
available on a facility -wide basis only, not for individual ouifalls. If any industrial activities or materials are or will be exposed to precipitation, the facility is
not eligible for the no exposure exclusion.
By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility or site,
and is obligated to comply with the terms and conditions of 40 CFR 122.26(g).
ALL INFORMATION MUST BE PROVIDED ON THIS FORM
Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4
A. Facility Operator InfoInformation1. Name: I t i o l ti l& I I A 61 � L_ I I I I I I I I I II I I I I I I I I I I 12- Phone: 91 l -3 9 fl
IQ I
3. Mailing Address: a. Street: I2L 1 01 1 014 iliCi 1Ill 19 3: 1 Li I I I-i1 I I I i I I I I t 1 I 1
b. City: IGi0iLiQijidQllAiQic. State: IIYId.ZipCode: 12171 SI 3101Jt } I I _1
B. Facility/Site Location Information
1. Facility Name: I� I I I �I 141 i Vi N I%!�IAI NI ji i_A (. I I I I I .I I I 11 1
2. a. Street Add((rr�ess: .� Q x
b. City: It2_injU DJ 0 tyel i n! I I I I I I I J_ I I! I I c. County: ItiiilI 12 YI )J? EJ ! I I 11
d. State: AL e. Zip Code: I2171,9['3101 — l I I I
3. Is the facility located on Indian Lands? Yes ❑ No
4. Is this a Federal facility? Yes No
5. a. Latitude: 1,71s'i 1z1J 1.219J b. Longitude: 1017 010 19, 1 2
6. a. Was the facility or site previously covered under an NPDES storm water permit? Yes No
b. If yes, enter NPDES permit number:
7. SIC/Activity Codes: Primary: 3� 4 1) 13 Secondary (if applicable): I i 1 1
8. Total size of site associated with industrial activity: ------ acres
9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? Yes No
b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no exposure
exclusion. However, your permitting authority may use this information in considering whether storm water discharges from your site are likely to have
an adverse impact on water quality, in which case you could be required to obtain permit coverage.
Less than one acre 71
EPA Form 3510-11 (10-99)
One to five acres ❑ More than five acres ❑
( Page 1 of 4
AUG 1 2 2003

NPDES n NO EXPOSURE CERTIFICATION for Exclusion from Form Approved
351113--FOR1n1 I EPA NPDES Storm Water Permitting OMS No.2040-0211
C. Exposure Checklist
Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future?
(Please check either "Yes" or "No" in the appropriate box.) If you answer "Yes" to any of these questions
(i) through (11), you are not eligible for the no exposure exclusion,
Yes
No
1.
Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing'I
or cleaning industrial machinery or equipment remain and are exposed to storm water
2.
Materials or residuals on the ground or in storm water inlets from spills/leaks
3.
Materials or products from past industrial activity
9
4.
Material handling equipment (except adequately maintained vehicles)
❑
X
5.
Materials or products during loading/unloading or transporting activities
❑
6-
Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where
exposure to storm water does not result in the discharge of pollutants)
7
Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers
S.
Materials or products handled/stored on roads or railways owned or maintained by the discharger
❑
K
9.
Waste material (except waste in covered, non -leaking containers [e.g., dumpsters])
10.
Application or disposal of process wastewater (unless otherwise permitted)
11.
Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated
(i.e.. under an air quality control permit) and evident in the storm water outflow
D. Certification Statement
i certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of "no exposure" and obtaining an
exclusion from NPDES storm water permitting.
I certify under penalty of law that there are no discharges of storm water contaminated by exposure to industrial activities or materials from the industrial
facility or site identified in this document {except as allowed under 40 Cl 122.26(g)(2)).
I understand that I am obligated to submit a no exposure certification form once every five years to the NPDES permitting authority and, if requested, to
the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where applicable). I understand that I must
allow the NPDES permitting authority, or MS4 operator where the discharge is into the fecal MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request. I understand that I must obtain coverage under an NPDES permit prior
to any point source discharge of storm water from the facility.
Additionally, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my
knowledge and belief true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility
of fine and imprisonment for knowing violations.
Print Name: I D 10 Al G I J,ftt—&t I I I I l I]. I_ I I I I I I I I I I I I I I I I
PrintTitte: LSIZITiCi MANAGIEIKI I I I I I i I I I I I I I_ I I I I I I i
Signature:
Date: 0 8 0$ il 3
EPA Form 3510-11 (10-99) Page 2 of 4